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TREASURY DEPARTMENT 
UNITED STATES PUBLIC HEALTH SERVICE 

HUGH S. CUMMING, Surgeon General 



SCHOOL HEALTH SUPERVISION IN 
MINNEAPOLIS, MINN. 



BY 



TALIAFERRO CLARK 

Surgeon 
United States Public Health Service 



REPRINT No. 683 

FROM THE 

PUBLIC HEALTH REPORTS 

August 12, 1921 
(Pages 1902-1936) 




2,1-z y^t v 2 — 



WASHINGTON 

GOVERNMENT PRINTING OFFICE 

1921 






SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS, MINN. 1 

By Taliaferro Clark, Surgeon, United States Public Health Service. 

A study of the system of health supervision operating in the public 
schools of Minneapolis, Minn., was undertaken by direction of the 
Surgeon General of the United States Public Health Service, on re- 
quest of the director of the department of hygiene of the Minneapolis 
Board of Education. Owing to a number of unavoidable circum- 
stances, and also because studies are being made of certain phases 
of the subject by volunteer organizations, the sanitation of the public 
school buildings was not included in this survey. Also no attempt 
was made to include the parochial schools. 

This survey was not made with the expectation of the immediate 
establishment of an ideal system of school medical supervision, the 
principles of which are well known and which at the present time are 
well-nigh impossible of accomplishment by the average community, 
but was undertaken more especially for the purpose of studying the 
actual practice, of making recommendations as to the manner in 
which the resources of the board of education may be used to the 
greatest advantage, and of suggesting lines of improvement which 
could be carried out with the resources which may become available 
in the near future. The board of education is not as much interested 
in what may be accomplished by school medical inspection in the 
distant future as it is in what can and shall be done at the present 
time properly to safeguard the health of the children attending the 
public schools. 

Organization of the City Government. 

In order that the limitations of school health supervision in Minne- 
apolis may be more readily appreciated, a brief outline of the organi- 
zation of the city government is given. 

The city government is administered largely by special boards, a 
part of whose membership is elected and a part exomcio. The 
mayor and a specified number of the members of the city council 
•serve as exomcio members on a number of these boards. For the 
purpose of this report consideration may be given only to the board 
of education, consisting of seven members, all of whom are elected, 

1 Reprint from the Public Health Reports, vol. 36, No. 32, Aug. 12, 1921, pp. 1902-1936. 

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'SCHOOL, HEALTH SUPERVISION IN MINNEAPOLIS. 3 

> and the board of public welfare. This latter board comprises seven 
members — two members of the city council and the mayor, who 
serve as exomcio members, and four other members who are ap- 
pointed by the mayor with the approval of the city council. 

The authority to maintain health supervision over the public 
schools is vested in the board of education and is exercised by the 
department of hygiene. The public health administration of the 
city is under the division of public health of the board of public 

welfare. 

Coordination of Functions. 

In May, 1920, the board of education, with the approval of the 
board of public welfare, designated the commissioner of public 
health to act also as director of the department of hygiene of the 
board of education and transferred to the account of the board of 
public welfare funds in the amount of the salary formerly paid the 
director of hygiene. This action by the board of education was a 
distinctly progressive step, both from the standpoint of economy 
and efficiency, and is in accord with the present tendency of govern- 
mental agencies to harmonize the work of the various boards and 
bureaus which have nearly identical functions. The coordination of 
the health work in the schools with the work of the city department 
of health extends, at present, only to the employment of a common 
director, and does not permit of the interchangeable utilization of 
the services of the personnel of the department of hygiene and the 
division of public health in school health work and general public 
health work. 

School Buildings and School Population. 

The board of education operates 84 public schools, including 6 
high schools, 3 junior high schools, a school for crippled children, 
and a farm school for boys. In respect to the latter, the board of 
education exercises no other function than that of supplying teachers. 
As is the case in practically all cities, the school building program 
has been of gradual evolution, and has not kept pace with increase 
in the population, owing to the lack of funds. For this reason some 
of the lower classes are overcrowded and a few of the school buildings 
are of rather ancient construction. In the main, however, the newer 
buildings are in keeping with the requirements of modern school 
architecture. 

The attendance at the public schools at the time of this survey 

was 60,146. Exclusive of the high schools, the attendance was 

50,080. 

School Health Supervision. 

Minnesota has no State school medical inspection law, but school 
medical inspection is permitted under regulations of the State board 
of health which have the force of law. 



4 SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 

The following are the requirements of the State board of health 
relating to school medical inspection, as of November 1, 1919: 

Sick school children to be reported. 

318. Teachers in cities and villages shall refer to the head of the school at once any 
pupil who — 

(a) Returns to school after an illness of unknown cause; 

(b) Appears to be in ill health; 

(c) Shows signs of a communicable disease (see lists under Regulations 300 and 

and 301); 

(d) Or has lice or other vermin. 

All such pupils shall be reported to the school physician for medical examination 
unless in the opinion of the head of the school the pupil's condition requires that he 
or she be sent home immediately or as soon as a safe and proper conveyance can be 
found. 

In such cases the pupil shall be sent home and the health officer of the sanitary 
district concerned shall be notified immediately by the head of the school. 

(Note. — A school nurse may perform the duties outlined, under the supervision 
of the health officer, when there is no school physician.) 

319. Each school physician shall make a medical examination of all pupils referred 
to him under Regulation 318, and such other examination of pupils, teachers, and 
janitors, and of school buildings, as in his opinion the protection of public health, the 
efficiency of the school, or the welfare of the individual may require, and shall report 
the results of such examinations to the local and to the State board of health. 

The medical inspection of pupils and the school nursing service are 
under the direction of the director of hygiene, who, as city commis- 
sioner of health, holds a dual position by special agreement of the 
board of education and the board of public welfare. Physical training 
formerly given under the direction of the director of hygiene is now 
under separate direction lodged in a special department of physical 
training of the board of education. No systematic work in health 
instruction is done in the schools under definite direction other than 
that provided by the school curriculum. Health talks are given by 
individual nurses without special supervision. Health instruction is 
also one of the prescribed duties of the school physician, but it is one 
seldom observed. 

A total of $89,125 was allotted by the board of education for health 
work in the schools during the calendar year, based on the following 
budget : 

Salaries. 

1 director, paid by board of public welfare $3, 720 

2 office assistants 2, 400 

5 medical inspectors 7, 600 

42 school nurses 58, 370 

3 dentists 4, 500 

6 bath attendants 6, 500 

Miscellaneous items, including medical, dental, and bath supplies . . 6, 035 

Total 89,125 



SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 5 

MEDICAL INSPECTION. 

Medical inspection is made by five school physicians appointed 
under civil service, four of whom serve part time only. The whole- 
time school physician devotes the morning hours to physical exami- 
nations, and in the afternoon he examines the children applying for 
employment certificates and the children in special classes. 

The number of school physicians is entirety inadequate for effective 
service, and as quickly as funds become available for this purpose their 
number should be augmented in the ratio of one physician to not more 
than 3,000 school children. 

Qualifications and duties of school physician. — The rules prescribed 
for the government of the Minneapolis public schools provide, as 
relating to school physicians, that — 

(a) They shall be graduates of a university or college, with at least two years' 
academic training and a degree of Doctor of Medicine, be graduated as an interne of 
one year's service from an accepted hospital, and shall be less than 50 years of age. 

(6) They shall be assigned to a group of schools and their hours shall be from 8.55 
a. m. to 12 m. each school day. They shall visit each school in their charge at least 
twice each week, according to schedule approved by the director, and at other times 
as required. Upon each visit they shall report immediately to the principal and leave 
written report of their work. 

(c) They shall examine each child referred to them by the principal for inspection, 
in a room set apart for this purpose, no other child being present. 

(d) They shall visit frequently the rooms of the schools to which they are assigned 
for the purpose of detection of cases of contagious diseases previously undiscovered, 
and to note the sanitary condition of the building, but they shall not make any special 
examination of pupils in the classroom. 

(e) They shall make such report as the superintendent or director requires. 

(/) They shall not offer their services or recommend other physicians for the treat- 
ment of public-school children. 

(g) They shall not give treatment to a pupil except at the request and in the presence 
of the pupil 's parent or guardian, except in case of accident or emergency. 

Under these regulations the school physician is required to visit 
each school in his charge at least once each week, except the schools 
having less than 150 pupils, which are visited only for monthly inspec- 
tions and on special call of the nurse or principal. At such times he 
examines cases of suspected contagious diseases, all children who have 
been absent from illness or for three days from any unexplained 
cause, children returning after previous exclusion, and all suspected 
cases of physical or mental defect referred by the principal or nurse. 
The duties of the medical inspectors as laid down have not been car- 
ried out in the school year 1920-21. All suspect cases and all three- 
day absentees and children returning after exclusion are inspected 
by the nurses. 

Routine inspection. — Each school physician is expected at the be- 
ginning of each term, and as often thereafter as the director may re- 
quire, to make a routine classroom inspection of each child in the 



6 SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 

schools under his charge. However, he is not permitted to touch the 
child during such inspection. Owing to such restriction, the time of 
the school physician could be utilized to greater advantage in other 
work. Nevertheless, he should be required to visit each classroom 
from time to time to advise with the teachers in respect to over- 
crowding, the seating of children, and the observance of sanitary 
requirements. In fact, the medical inspectors are now required to 
confer with the teachers and principals, and to visit classrooms 
when requested. 

Physical examination. — No child is given a physical examination 
except with the consent of its parent or guardian. The following 
notice to parents is sent previous to beginning such examinations: 

Form No. 121. 

Minneapolis Public Schools Health Supervision. 
Notice to parents: 

HEALTH SUPERVISION will be started soon in the school which your child is attending. 

This supervison is for the purpose of detecting contagious disease, and to see if the children 
are in such a condition as to be able to do the school work properly and without risk to them- 
selves. 

All examinations will be made in the presence of the school nurse by an inspector appointed 
for that purpose by the board of education. 

If you object to such an examination of your child being made, notify the principal of the 
school, within one week of receipt of this notice, IN WRITING. If such written objection is 
not made, it will be presumed that you approve of such an examination, and your child will 
be examined when its turn comes. 

By order of 

The Board of Education. 

Physical examinations are required of children entering school for 
the first time, except those exempted by parental request, and the 
examinations proceed in regular order from the lowest to the highest 
grades. However, it is required that classes of the same grade be 
examined in regular order in each school of the groups under each 
school physician's charge. 

At present, owing to their limited number, the school medical 
inspectors are principally engaged in the physical examination of the 
children of the first and eighth grades. These examinations take 
place in the morning hours, and each inspector is assisted by a special 
nurse detailed for this purpose. The regular school nurse takes no 
part in the physical examinations and, as a consequence, has no first- 
hand knowledge of the physical defects discovered during these 
examinations and is, therefore, not in position to evaluate the serious- 
ness of the defect in individual cases, an important factor in securing 
the cooperation of the parent in follow-up work. The director of 
hygiene does not underestimate the value of the presence of the 
regular school nurse during physical examination, but because of the 
manifold duties of the nurses, the number of buildings each nurse is 
required to visit, and the importance of the nurse's presence in each 
of these buildings at some time during the school day, it has been 



SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 7 

found impossible with so small a force to have the school nurse 
present at the physical examinations. 

The need is very apparent for the • employment of an additional 
number of medical inspectors and the reorganization of their work 
in a manner to insure the correction of the greatest number of ham- 
pering physical defects. A school medical inspection made for the 
sole purpose of discovering and recording physical defects, without 
an attempt to secure their correction, is not worth undertaking, and 
the time, money, and energy expended may be considered to a great 
extent lost. Furthermore, the regular school nurse should be present 
at such inspections and should participate in something more than 
mere clerical work. The school physician who does not explain to the 
school nurse the nature and seriousness of defects needing immediate 
attention will not secure the best results from follow-up work. 

Extent of examination. — It is required that each child be thoroughly 
examined for the following conditions: 

1. Defective vision. 

2. Defective hearing. 

3. Defective nasal breathing. 

4. Hypertrophied tonsils. 

5. Tuberculous lymph nodes. 
6.. Pulmonary disease. 

7. Cardiac disease. 

8. Nervous diseases (chorea, etc.). 

9. Anemia and malnutrition. 

10. Orthopedic defects. 

11. Defective teeth. 

12. Defective speech (its cause). 

13. Abdominal defects (in boys only). 

Owing to the lack of physicians the medical inspection is too 
superficial; no absolute diagnosis is made, and suspected cases are 
referred to the mother with the. recommendation that she send the 
child to the family physician. 

The method of medical inspection should be standardized and the 
personal equation of the individual inspector eliminated as much as 
possible. Under the existing arrangement the medical inspector 
visits a particular school in his district from day to day and, assisted 
by a special nurse, spends his time in making the medical inspection 
of the children in a given grade. In consequence of this arrangement, 
weeks may elapse before he even enters some of the schools of his 
district. 

Even with the present inadequate force the work of the school 
physicians can be reorganized to advantage. The medical examina- 
tions should be confined for the present to the children who wish to 



8 SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 

leave school for employment; to the children of the first grade, in 
order to discover those who are entering school suffering with a phys- 
ical handicap; and to the children of the second grade, in order to 
determine what has been done in the course of a year for the correc- 
tion or relief of physical defects. Remediable physical defects can 
be corrected most easily in their incipiency. It is a wise provision, 
therefore, from both the educational and health standpoint, to detect 
these handicaps and insure their removal as soon as possible after the 
child has entered school, and much better than to wait for an inspec- 
tion which is made at a later age period. 

Under the scheme which was outlined in September, 1920, and 
which was in effect at the time this study was made, reports have 
been made of approximately 8,000 physical examinations of the first 
year enrollment and 4,360 children of the eighth grade. It was 
expected that the physical examination of 5,721 children comprising 
the fourth grade would be completed during that term. With an 
increased number of physicians the examination should be extended 
to include other grades. 

The inspector should be required to visit every school in his district 
in rotation on a particular day. At the time of such visit he should 
make the desired physical examinations of a number of children in 
a given grade and a more specific examination of the children dis- 
covered by the nurse in classroom inspections, or referred by the 
teacher, or discovered by himself at the time of his previous visit 
whose condition warranted the written consent of the parent or guar- 
dian to a more detailed examination than is permitted under existing 
regulations, provided that the written consent of the child's parent 
or guardian shall have been previously obtained by the school nurse 
in the interval between the medical inspector's visits. 

The object of medical inspection as now practiced is to make a 
rapid survey, with a limited force, for the purpose of detecting gross 
defects, in order that data may be available to enable the board of 
education properly to evaluate the size of the problem and to demon- 
strate the laxity which has apparently been in evidence in past years. 
The work already accomplished under the director of hygiene empha- 
sizes the fact that for the scheme, as outlined above, to be as com- 
pletely effective as desired, it would be necessary to employ an addi- 
tional number of school physicians. 

Exclusion and readmission. — Rather definite rules have been pre- 
scribed for the exclusion of children, namely — • 

(1) All children showing signs or symptoms of smallpox, diphtheria, 
scarlet fever, measles, chicken pox, whooping cough, mumps, infan- 
tile paralysis, or tuberculosis in the active stage. 

(2) Cases of pediculosis with live pediculi or with nits, when in the 
judgment of the physician they are a menace to the other children. 



SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 9 

(3) Children affected with contagious eye and skin diseases whose 
parents have persistently refused to obtain treatment. 

(4) Children of families in which a member or members have one 
of the diseases enumerated under (1), except tuberculosis and except, 
in the case of measles, mumps, chicken pox, and whooping cough, 
children who have previously had these diseases. Each excluded 
child is given an official exclusion blank, previously filled out, signed 
by the principal, and sealed. 

Children suffering from acute conjunctivitis, pediculosis, skin dis- 
eases, and trachoma are referred to the family for treatment or to 
the nurse for instruction. 

Children quarantined under the rules of the health department are 
readmitted only on written certificate of that department. Children 
returning after having had contagious diseases that are not quaran- 
tined by the health department are readmitted after examination by 
the school physician or on written certificate of the health department. 

Children excluded for tuberculosis may be readmitted only upon 
the personal written certificate from the health commissioner. 

NURSING SERVICE. 

A total of 42 nurses are engaged in school nursing work, as follows : 
One supervising nurse, 1 assistant, 34 regular school nurses, 5 special 
nurses who assist the school physicians in the physical examination 
of children during the forenoon and attend special clinics during the 
afternoon, and 1 nurse supplied by the Junior Red Cross for duty in 
the school for crippled children. This latter nurse, although her 
salary is paid by the Junior Red Cross, is under the direction of the 
director of hygiene. 

The nurses regularly assigned to school districts make class room 
inspections and examine children referred to them by teachers and 
principals. Usually this work is limited to the morning hours. They 
do home visiting and conduct children to clinics in the afternoons. 
The nurses are required to be on duty until 1 p. m. on Saturdays. 

Appointment. — The school nurses are appointed under civil serv- 
ice regulations. They must have a high school education, be 
registered in the State of Minnesota, and have had at least three 
months' training in child care. School nurses are paid for only 
10 months of the year. However, five nurses were employed dur- 
ing 1920 for duty in the summer schools. 

Ratio of nurses to schools. — Ordinarily, each nurse has two schools 
under her supervision, but in some instances a nurse may have as 
many as three schools. In addition to the schools that are visited 
regularly each day by a nurse, 10 of these nurses are required to 
visit once or twice a week the smaller schools of 100 pupils or less 
which may be located in their district. 
65514°— 21 — -2 



10 SCHOOL HEALTH SUPEKVISION IN MINNEAPOLIS. 

The average number of pupils to each school nurse is 1,769. Ex- 
clusive of the high schools, this average is 1,472 school children. 
The highest number of children to the nurse is 3,938, and the smallest 
is 759. 

Duties and qualifications of school nurse. — The duties and quali- 
fications of school nurses are prescribed by the rules for the govern- 
ment of Minneapolis public schools as follows : 

They shall assist the physician in the examination of children, and seek to promote 
the health and well being of the children in the district. 

(a) They shall be graduates of a general or children's hospital, and at time of ap- 
pointment be between the ages of 25 and 40 years. 

(b) They shall be assigned severally to a group of districts with hours from 8.30 
a. m. to 5 p. m. on school days, and 9 a. m. to 1 p. m. on Saturdays. 

(c) They shall wear the required uniform while on duty. 

(d) They shall receive all pupils referred by the school physician or principal, in 
a room assigned for that purpose. 

(e) They shall give bath-room service as directed, care for children who may be 
taken to a dispensary, and shall visit the homes of the districts as time will permit. 

The school nurse is required to make classroom inspection from 
time to time, with special reference to communicable disease and 
animal parasites. She also makes notation of obvious and easily 
detected physical defects. She is very properly cautioned not to 
make definite diagnosis in referring cases to parents for physical 
defect corrections; but where such references are made by the 
medical inspection, as definite diagnosis as is consistent is made. 
However, under the present temporary arrangement, many children 
suspected of being in need of medical and surgical attention are 
referred to the parents without a definite diagnosis. This is a serious 
defect in the medical inspection service and is not likely to obtain 
results in the correction of physical defects. Parents, as a rule, seek 
medical advice only in times of serious sickness and are notoriously 
lax in providing the necessary attention for the relief of defects 
which do not obviously incapacitate the child. Any procedure 
which requires the mother to undergo the extra expense of employing 
a physician to make the diagnosis is not likely to meet with active 
cooperation in the average home. Under the regulations, no child 
is to be examined in the classroom. Cases of suspected contagious 
diseases coming within the purview of the quarantine regulations of 
the department of health are referred to the principal for exclusion, 
and the health department is notified in each instance by telephone 
and in writing. Children who are sent home for illness other' than 
suspected communicable diseases are directed to return at a specified 
time when the nurse will be present, and are given a card filled out 
by the nurse and signed by the principal, which states the cause of 
sending the child home and gives the date of his expected return. 



SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 11 

Home visits. — -The nurse is required to visit the parents at the home 
and explain the nature of defects and to urge the necessity of treat- 
ment, unless parents, within three days after notification, visit the 
nurse at the school. Subsequent visits are made from time to time 
until treatment has begun or the parents refuse to secure treatment. 
If the parent is unable to take the child to the dispensary, the nurse 
is permitted to do so, but must first obtain a written request signed 
by the parent or guardian. Nurses are not permitted to visit cases 
of contagious disease quarantined by the department of health. 
Nurses are also required to visit all pupils who have been absent 
three or more days for any unexplained cause, and a report is required 
to be made to the health department and to the principal of all cases 
of contagious diseases found. 

SPECIAL CLASSES. 

The care of handicapped children has long received special atten- 
tion by the State of Minnesota, and from time to time institutions 
have been established for their care and training. The State School 
for the Deaf was opened at Faribault in 1863, and, later, the State 
School for the Blind, also at Faribault. In 1882 the School for the 
Feebleminded, located at Faribault, was opened. The School for 
Dependent Children, located at Owatonna, was opened in 1886. 
The first buildkig of the Home for Crippled and Deformed was erected 
at Phalen Park, St. Paul, in 1910. 

In 1915 the legislature enacted a law providing for the establish- 
ment of special classes in the public schools for the deaf, blind, sub- 
normal children, and children with speech defects. Under the pro- 
visions of this law, defective children who are living at home and who 
are unable to profit by the regular classes in the public schools are 
given immediate and individualized training. 

Under this law, on application, any special, independent, or com- 
mon-school district complying with its provisions may be permitted 
to establish or maintain one or more schools for the instruction of 
deaf, blind, mentally subnormal children, and children with defective 
speech. 

Permission to establish such special classes may be granted to dis- 
tricts that have actual attendance of not less than five deaf children 
between the ages of 4 and 10 years, who may come under the pro- 
visions of this act. Separate classes and separate teachers are re- 
quired for the deaf, blind, mentally subnormal children, and children 
with defective speech. 

The State grants an allowance of $100 for each defective child in- 
structed in special classes of at least nine months' duration. 



12 SCHOOL HEALTH SUPERVISION" IN" MINNEAPOLIS. 

Sight-saving classes. — Operating under the provisions of the State 
law, the city board of education maintains three classes for children 
under 16 years of age whose vision is impaired to such a degree that 
it is difficult or impossible for them to keep pace with their classes 
without special aid. Furthermore, other children who present un- 
mistakable evidence of positive injury to their eyesight by regular 
class work are admitted to these classes. The object is to instruct 
these children with the least eye strain, to create in them a life habit 
of protecting their own vision, and to provide vocational training. 

Standards of admission to sight-saving classes. — The following 
classes of cases are eligible to admission to special classes: 

1. Myopes of 8 dioptrics or more. 

2. Myopes whose vision can not be brought up to one-half nor- 

mal vision (20/40) . 

3. Progressive myopia. 

4. Children having macula or leucoma of the cornea, or optic 

atrophy with vision less than 6/15. 

5. Astigmatism with glasses 20/70 or less. 

6. Hyperopia of more than eight dioptrics, with symptoms of 

asthenopia. 

7. Keratitis: In the interstitial type, if the vision remains low 

after the eye has been quiet for three months, or in per- 
sistent recurrent conditions while under treatment. 

8. In congenital cataracts or secondary cataracts where no acute 

condition is present, with vision 20/50 or less. 

9. Congenital malformations where the vision is 20/70 or less. 
10. In all chronic diseases of the fundus where the vision is 20/40 

or less. 

Pupils are referred by principals, nurses, and school medical 
examiners. 

Special equipment. — The classrooms are arranged with a special 
view to protecting the children from eye strain, due regard being 
paid to the location of the classroom, type of blackboard, printing, 
paper, crayons, and teaching methods. The children receive instruc- 
tion in the special classes by properly qualified teachers, but are 
allowed to join their regular classes for recitation. 

Medical supervision is maintained by a physician not connected 
with the school system, whose salary is paid by an outside agency. 

Special classes for the deaf — A class for the deaf was first organized 
in 1915. At the time of this study five such classes were in opera- 
tion, each with a special teacher, with an attendance of 44 children. 
Children are referred to these classes by principals, medical inspec- 
tors, and nurses, and are received from clinics. The age limit for 
attendance is from 4 to 16 years, and the number of children is limited 
to 10 for each teacher. Owing to the fact that the eyes of the deaf 
child, in a sense, take the place of hearing, careful supervision should 



SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 13 

be maintained of the eyesight of the children attending these classes. 
At present no special effort is being made to conserve the vision of 
these children. 

The provision setting an early age at which children may be ad- 
mitted to special classes for the deaf is a wise one. It is more reason- 
able to defer beyond the usual age for school entrance, sending a child 
whose sense of hearing is normal to school than to pay *no educational 
attention to a deaf child until after he arrives at the average school 
age. During the earlier years of life he has only the limited sign 
language, and unless special teaching is commenced at an early age, 
the years of the most rapid language formation are lost. Regula- 
tions promulgated by the British Board of Education provide that no 
child shall be admitted to classes for the deaf who is not 2 years of 
age, and further that no child may be retained in such classes who is 
physically and mentally in condition to profit by the regular courses, 
or who is incapable of profiting by special class instruction. 

Classes for correcting speech defects. — Classes for special instruction 
in speech are operated in four schools, under the direction of two 
special teachers. These classes are only indirectly related to the 
school medical inspection system. However, in addition to the rou- 
tine inspection for the discovery of communicable diseases and other 
physical defects, very careful and special examination of each child 
enrolled in a correctional class should be made to determine the cause 
of the speech defect— whether functional or due to congenital word 
deafness, defects of the articulative apparatus, or defects due to im- 
perfect nervous control of the speech-producing mechanism. 

Furthermore, imperfect speech is quite common among mental 
defectives. It is important from the pedagogic standpoint, there- 
fore, that the correct mental status of each child be determined by a 
careful mental examination previous to his admission to the class, 
and that the teacher be notified of the results of such examination. 
Since imitation is an essential factor in the acquirement of perfect 
speech, the school nurse should be required to visit the homes of 
children attending speech classes for the purpose of studying the 
child's environment with special reference to the presence of speech 
defects in members of the family not attending school, and the 
amount of cooperation that may be expected of the parents. 

Special classes for subnormal children. — A total of 16 special classes 
are maintained in 11 schools for the instruction and training of 
children who are apparently retarded in mental development and 
unable to profit by the usual classroom instruction. The children 
attending these classes receive State aid for instruction purposes. 

The number of children admitted to each class is restricted to 15, 
and each child is given a careful examination by a competent psy- 
chologist. 



14 SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 

The causes of retardation may be due wholly or in part to paren- 
tal, economic, or environmental influences; to physical, mental, and 
temperamental characteristics of individual children; to faulty teach- 
ing methods; to an unsatisfactory curriculum; or to poorly qualified 
teachers. Work of this character is of the highest importance, not 
only from the standpoint of its value in giving such children an 
opportunity to> readjust themselves as far as possible to the demands 
of modern life, but also from that of the economic loss caused by 
children unnecessarily repeating grades. It is also of great value in 
focusing public attention on the need of providing adequate facili- 
ties for the care, training, and treatment of this unfortunate class of 
the population. 

As the result of a cooperative teachers' referendum made by the 
United States Public Health Service in the course of a State-wide 
survey of dependency, delinquency, and feeble-mindedness, it was 
reported that of 32,480 children then in school approximately one- 
fifth had failed to advance normally, owing to some handicap falling 
within the field of mental hygiene. Other studies made by officers 
of the service have revealed definitely as feeble-minded from 0.3 to 
1.3 per cent of the school children who were examined. In addition 
to the feeble-minded and the border-line feeble-minded, a number of 
children (0.4 per cent according to one of the author's studies) are 
observed in school who fail to progress because of unbalance of other 
functions of the sensorium and not because of defective intelligence. 
This type can not be classified by formal psychological tests, 
but requires for this purpose a careful psychiatric examination. 
Such children are usually more disturbing factors in school life than 
are the feeble-minded. For this reason all children retarded in school 
work, including the so-called border-line feeble-minded cases, should 
also be given a careful examination by a trained psychiatrist. 

The role of malnutrition and of hampering physical defects, includ- 
ing defective hearing, imperfect vision, diseased tonsils, and adenoids, 
in causing lack of progress in school work, is well known to educators. 
It is of prime importance, therefore, that in addition to the psychologic 
and psychiatric examinations, each candidate for these special 
classes should receive a careful physical examination, with a view to 
securing the correction of the potential physical causes of his lack of 
advancement. 

No system of instruction for the retarded pupil will be effective 
without competent follow-up work in the home for the purpose of 
securing parental cooperation and for the discovery and correction, 
as far as may be possible, of injurious economic and environmental 
contributing factors. 

The special examinations and instruction of retarded children and 
the follow-up work in the home are very definite factors in mental 



SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 15 

hygiene. The average parent of a feeble-minded child is either 
ignorant of the child's potentialities for good or evil or else shirks the 
responsibility and considers the unfortunate one in the light of a 
family skeleton which is not to be discussed. As a result many of these 
children are neglected, fall easy victims of vicious habits, and come in 
conflict with the social customs and usages established by society for 
its own protection. Through the instrumentality of child health work 
in the schools, the general public will be brought to a better apprecia- 
tion of the subject, and parents, instead of evading the question, will 
voluntarily seek the advice of and cooperate with the school medical 
authorities in the case of a potentially feeble-minded child who is 
retarded in school work, with no more hesitancy than if the child 
were suffering from one of the ordinary diseases of childhood. 

Classes should be organized in all the schools of the city, and steps 
should be taken to segregate eventually all of the definitely feeble- 
minded children in a school, pending adequate State provision for 
the institutional care of those who exhibit marked antisocial ten- 
dencies. 

The name "special classes for subnormal children" should be 
changed to "special classes for retarded children," thus relieving the 
children attending them of the stigma of subnormality. These 
classes should be open to normal children who do not progress in a 
satisfactory manner and should be operated as a clearing house, 
both for those children who profit by individualized instruction and 
who may eventually be returned to their regular grades, and for the 
segregation of the definitely feeble-minded who do not profit by 
such instruction beyond a certain point and who should be sent to a 
special school or placed in a separate class. 

School for crippled children. — A school for crippled children was 
established by the board of education in 1920, and is organized in 
a church building acquired by the board in the purchase of addi- 
tional grounds for a neighboring school. 

The director, her assistant, and the teaching staff are supplied by 
the board of education. The nurse and the orthopedic surgeon are 
supplied by the Junior Red Cross. 

Crippled children are referred by school principals, medical exam- 
iners, school nurses, clinics, and by other agencies. A child does 
not necessarily have to be attending school to be eligible for admis- 
sion to this special school. At present 72 children are enrolled, 
which is almost the capacity of the building. 

The children are brought to the school and returned to their homes 
in two busses, one provided by the Junior Red Cross and the other 
by the Elks' Club. The busses are maintained and operated at the 
expense of the board of education. 



16 SCHOOL. HEALTH SUPERVISION IN MINNEAPOLIS. 

The regular class work is supplemented by group and individual 
exercises, and by massage and corrective treatment in selected 
cases. Lunch is also provided. 

No general health supervision of the children is maintained by 
the department of hygiene except that by the school nurse. Ortho- 
pedic service is given by a specialist, who, very naturally, is more 
interested in the correction of orthopedic defects than in general 
health supervision. The children of this school should be included 
with those of other special classes which come under the special 
supervision of a whole-time school physician. 

SCHOOL CLINICS. 

Eye clinic. — Supplementing the work of the sight-saving classes, 
the board of education has sanctioned the establishment of an eye 
clinic in one of the schools. This clinic is open from 1 to 4 p. m. on 
school days. It is in charge of two attending surgeons, paid by the 
Women's Clubs of Minneapolis, assisted by a nurse, paid by the 
board of education, which also furnishes the necessary drugs. Glasses 
are furnished at cost under contract, and the contractor returns to 
the board of education 5 per cent of the funds received, in the form of 
free glasses for necessitous children. In addition to refraction work, 
inflammatory conditions of the eyes are also treated at the clinic. 
The children are referred to the clinic by nurses, by medical examiners, 
and by the teachers and principals. In view of the present limited 
facilities, greater care should be exercised in the selection of children 
to be referred to the eye clinic than is now being given to this matter. 

Considerable complaint is voiced by the teachers and principals 
because of the loss of time in school work that is due to the use of 
atropin as a mydriatic. While atropin undoubtedly is the most 
efficient of mydriatics, a number of school medical authorities use 
homatropine, because it disturbs the vision for a shorter time than 
does atropin. 1 

The number of visual defects found among school children varies 
in different communities Approximately 30 per cent of all school 
children have some more or less serious visual defect. In one com- 
munity studied by the writer, 5.3 per cent of the boys and 8.2 per 
cent of the girls had marked refractive errors, requiring the imme- 
diate fitting of glasses. Obviously, one eye clinic operating only a 
part of each school day can make but little impression even when, 
as is frequently the case in Minneapolis, children are referred to 

1 According to N. Bishop Harman, homatropine in watery solutions is uncertain, but it is reliable if 
dissolved in castor oil. He advocates the use of a 2 per cent solution of homatropine and cocaine in castor 
oil. Unfortunately, this solution causes a smarting sensation when first introduced into the eye and he 
advises, therefore, that a drop of the solution should be placed in the lower fornix of each eye in quick 
succession before the eyes are allowed to close. The child is then required to sit with the eyes closed or 
bandaged from one-half to one hour. By this method the child experiences the least discomfort. 



SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 17 

dispensaries. Furthermore, the work as now conducted is more or 
less independent of the school medical system, which is not good 
practice. 

Dental clinics.— -Three school dental clinics are in operation. The 
dentists are appointed under the civil service. The salary is $150 
a month for 10 months (Sept. 1 to June 30). In addition, $15 per 
month is allowed the dentist as a payment for the use of his own 
instruments in the clinics. The clinics are open five days in the week 
from 1 to 4 p. m., but they do not open on holidays or Saturdays. 

The children are brought to the clinic by the school nurses. They 
are children referred by the teacher or discovered by the nurse in 
classroom inspection or by medical inspectors in the course of routine 
physical examination. Treatment is approved by the principal for 
those children whose parents are not able to pay. This recommenda- 
tion must be countersigned by the parent giving permission. 

In addition to the three dentists, there has bgen recently appointed 
an instructor in oral hygiene at $150 a month for 10 months in the 
year, whose duty is to exercise general supervision over the clinics 
and to standardize the work. 

Of the defects observed in school children, decayed teeth and 
diseased gums constitute easily a large majority. Owing to the 
great number of children who suffer from decayed teeth, the effect 
of diseased conditions in the mouth on the physical well-being and 
school progress of the child, and the promptness with which tangible 
results of corrective dental work become evident, the establishment 
of a school dental clinic stands first in the list of measures which 
should be undertaken for the conservation of the health of school 
children. Health is an intangible thing from the standpoint of a 
well man or woman. For this reason it is extremely difficult to 
secure public support of measures for the protection of public health. 
The average parent is not greatly interested in school health super- 
vision, because it constitutes a promise of indefinite fulfillment. 
With emphasis placed on dental work in the schools, the parent is 
readily brought to see that something definite has been done for the 
benefit of the child. In fact, the child who has been treated in the 
clinic will himself serve as a constant reminder to the parent of the 
work which has been done. For this reason the extension of dental 
work in the schools will serve to arouse the interest of the public at 
large in other forms of school health supervision. 

The greatest good will not be accomplished by the correction of 
dental defects alone; this must be supplemented by instruction in 
mouth hygiene and in the conduct of toothbrush drills. 

The extent to which dental work is practiced in schools varies in 
different communities. In general, the teeth of all children under 
65514°— 21 3 



18 SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 

* 

12 years of age should be attended to in the school dental clinics. 
Restriction of dental care to necessitous children should be avoided'. 
The objection of a few dentists that this is an abuse of dental charity, 
is not valid, because there are not enough dentists in any one city 
properly to care for the dental defects which may be found. More- 
over, many dentists do not care for clients who can pay only a 
minimum fee. The dental work in the schools will ultimately bring 
more work to the practicing dentist. As it becomes more and more 
general, an increasingly large number of children will grow to adult 
age who will regularly consult a dentist because of the knowledge of 
the importance of conserving the teeth which was acquired in school. 

The present number of dentists employed is entirely inadequate. 
On an average, a dentist will require about 20 minutes per child, and 
working as they do only a part of each day, a number of children will 
fail to receive the attention that they so badly need. 

As funds become available, the number of school dentists should be 
increased. Furthermore, the great value of any health work in the 
school is preventive. With the present limited dental force, the work 
should be largely restricted to children just entering school, and 
attention should be given to only such other- children as require 
immediate relief from neglected conditions. 

The work of the dentist can be made to cover a much larger field 
if supplemented by the employment of mouth hygienists to do pro- 
phylactic work. Dental hygienists should be in the proportion of 
from two to four to each dentist. Not only may they be secured at 
less salary than that commanded by the dentist, but in addition 
they limit the amount of work which the dentist will have to do 
through the prevention of dental decay. 

Even with the present limited dental force, the amount of work 
done could be more than doubled by employing dentists on a whole- 
time basis and keeping the clinics open during the whole school day 
and on Saturdays. 

In order to prevent undue loss of time from other duties by the 
school nurse, certain clinic hours should be set aside for the children 
of a designated school, and the maximum amount of work done at 
each sitting should be compatible with the particular child's comfort 
and endurance. Frequent visits to the clinic without obvious 
results will prove irksome to mothers who have to get the children 
ready, and may possibly excite adverse criticism. 

NUTRITION WORK. 

Nutrition classes. — Nutrition classes have been organized in five 
schools, under the auspices of the Woman's Community Council of 
Minneapolis. These classes are in charge of an instructor, who is 
paid by the Woman's Community Council. Medical supervision is 
maintained by a physician not connected with the school system. 



SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 19 

The children are subjected to periodic height and weight measure- 
ments, and advice and instruction are given by the nutrition worker. 
These classes are not attended by the mothers, and, in fact, it appears 
that no attempt is made to secure their attendance. This is a very 
serious handicap to the success of the class work, because, in a large 
number of instances, individual children are unable to supply the 
workers with needed information. Also many children are either 
unable or neglect to inform their parents of what is expected of them 
at home. The nutrition worker is assisted by the school nurse, who 
is paid by the board of education. 

It has been 'found impossible for the force of workers employed at 
the time of this study to undertake follow-up in nutrition cases, 
therefore no follow-up work in the home is carried on to secure the 
cooperation of the parents, in consequence, the children attending 
these classes do not derive the maximum benefit which otherwise 
might be expected from the instruction and advice given them. The 
work in the school should be supplemented by periodic visits to the 
child's home, in order to secure the assistance of the parents in having 
the child follow a definite regimen in respect to exercise, hours of 
sleep, periods of rest, the eating of proper food, and ventilation of 
the bedroom. 

Owing to the fact that this work is not definitely connected with 
the school medical inspection system, due regard, apparently, is not 
paid to the selection of children for admission to these classes and to 
the detection and correction of the hampering physical defects which 
are frequently contributing causes to a state of malnutrition. Special 
attention should be paid to the correction of dental defects of the 
children attending these classes. A very high percentage of under- 
nourished children show evidence of mouth sepsis. Of 270 under- 
nourished children which are now under the supervision of the Public 
Health Service, it was found that 33 per cent had from one to four 
cavities, 48 per cent had from four to eight cavities, and a number of 
them showed nine, ten, and eleven cavities. 

Milk at reduced cost. — Through the effort of the Parent-Teachers 
Association, milk is now supplied to the children in 34 schools at 
3 cents the one-half pint. A small fund is available for supplying 
milk to necessitous children. The milk is usually served by volun- 
teer workers at morning recess and is taken by the children through 
a straw. 

This work is not well systematized and is not included in the pro- 
gram of school health administration. 

School lunches. — Lunches are provided at minimum cost, under 
the supervision of a director, to the junior and senior students of the 
high schools. Free lunches and a noon-day meal are served to the 
children of the open-air school, at the expense of the board of educa- 



20 SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 

tion. Penny lunches are available in a number of schools of the 
city. This service is operated by the board of education. 

Open-air school. — The board of education maintains one open-air 
school with capacity for 100 children. Children are referred to this 
school by principals, medical inspectors, and nurses. The school is 
designed primarily for children exhibiting predisposition to respira- 
tory diseases, such as anemic children, children with defective nutri- 
tion, and children from a tubercular environment. The board of 
education furnishes free street-car transportation when necessary. 
A number of the children attending the open-air school come from 
school districts other than the one in which the school is located. 

In addition to classroom instruction due attention is given to the 
observance of rest periods and the provision of extra clothing, blan- 
kets, and food. Each child is given milk on arriving at school, gruel 
or mush at the morning intermission, and lunch at noon consisting 
of bread and butter, soup, meat, and vegetables. Finally, just 
before starting for home the children are given hot or cold milk, 
depending on the weather and the personal taste of the child. 

A nurse is constantly on duty during the hours the school is in 
session. Supplementing her other duties, she supervises the weekly 
weighings and periodic baths. 

The children are given no physical training other than class 
calisthenics. 

Approximately 10 per cent of the children attending the schools 
located in certain sections of the city would benefit by attending 
an open-air school. As funds become available, the board of edu- 
cation will no doubt extend this service, establish additional open- 
air schools, and organize open-air classes in the regular schools for 
children who are physically below par but not to such degree as 
would warrant sending them to open-air schools. 

Owing to the limited capacity of the building, greater care than at 
present seems to be exercised should be given to the selection of 
children who may be admitted to this school, and more careful medical 
supervision should be maintained of the children already attending 
the school, in order that they may return to their regular classes as 
promptly as possible. A habit of invalidism should not be encour- 
aged by an unnecessarily prolonged attendance. Furthermore, it is 
only by careful medical supervision that the best results can be 
obtained and the greatest use made of existing facilities. 

The work of this school, which is excellent in so many respects, 
suffers from the lack of follow-up work in the homes of the attending 
children. Unless home conditions are satisfactory and the full and 
intelligent cooperation of the parents is assured, the benefit of the 
open-air school regimen is largely lost. A child who is injudiciously 
fed at home, allowed to run the streets, attend moving-picture shows, 



SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 21 

keep late hours, and required to sleep in a crowded and unventilated 
bedroom, will not obtain the maximum benefit from the instruction 
and routine of the open-air school. 

Physical training. — Formerly physical training was an essential 
part of the school health supervision system under a common director. 
However, in April, 1919, the board of education separated the depart- 
ment of health and physical training and established in its place a 
department of hygiene and a department of physical training, each 
under a separate director. In the light of the present-day tendency 
to unite under centralized administrative control all public agencies 
engaged in a common line of work, and especially in view of the 
intimate relationship of physical training to medical inspection and 
health instruction, the action of the board may be subject to criticism. 

In actual practice, physical training in the Minneapolis schools 
consists in marching, corrective calisthenics, and games. As is the 
case in many school systems, a comparatively short length of time 
is allowed for physical training. In the schools having gymnasiums, 
physical training is given for two 30-minute periods weekly, and in 
schools without them, 16-minute daily corrective calisthenics are 
given. In the high schools, two 40-minute periods weekly are given 
over to physical training. Efficiency tests are made every month, 
and a physical examination is required of every pupil before he is 
allowed to take part in athletic contests. This examination is 
made by physicians not connected with the school system. 

This work is carried on by four instructors, two of them being 
women who are assigned to the high schools. About 60 per cent of 
all the pupils of the public schools receive instruction upon two or 
three days each week. 

R. O. T. courses are optional and limited to students attending the 
junior and senior high schools. 

SCHOOL RECORDS. 

A fairly comprehensive ystem of medical records an 1 notification 
forms of various descriptions is maintained in the Minneapolis public 
schools, including a monthly sanitary report, a daily leport by the 
physicians and the school nurses, dental and eye clinics, open-air 
school records, and the physical record of the pupils. The number 
and variety of record forms in use in any school system is largely 
determined by the lo:al requirements and conditions, which of 
necessity vary from time to time, and no hard and fast rules relating 
to them can be laid down. In general, it is important that accurate 
data be obtained and preserved regarding the physical condition of 
the children attending school, which should be at all times available 
for the guidance of teachers, nurses, and medical authorities. Great 
care should be exercised in recording physical data. It is not suffi- 



22 SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 

cient for the school physician to heck a disability as an " eye defect," 
" orthopedic defect," etc., but in each instance the defect should be 
recorded in specific terms, such as "myopia," "flat foot," etc. At 
present but little use is made of the statistical material collected 
during school medical inspections, and in consequence the board of 
education is without definite information in respect to the number of 
defective children attending school, the nature and seriousness of 
these defects, and the extent to which medical inspections and noti- 
fication to parents have resulted in the correction of remediable 
defects. However, plans are maturing for the utilization of such 
data to the greatest advantage. 

The child's physical record should accompany the school record 
from class to class and should show, in addition to the defects with 
which the child is or has been suffering and what has been done for 
their correction, a record of the child's absences from school on account 
of sickness, a monthly record of absences due to communicable dis- 
eases, a monthly record of weight, a record of height and weight at 
the beginning and at the close of the school year, a statement of the 
child's school progress, and the grades repeated, if any. 

Owing to many factors, it is doubtful if any uniform standard of 
physical development of children can be devised applicable to the 
Nation as a whole. It is desirable, therefore, that each community 
determine its own standard. It is very necessary that accurate 
height i nd weight measurements be made from time to time, so that 
standards of physical development may be calculated for children of 
each sex and at different age periods, to serve as the basis to de- 
termine the need of special attention and the effect of attendance at 
nutrition classes and of other measures on the child's physical well- 
being. 

Health Instruction. 

In common with a large number of other school systems, Minne- 
apolis has adopted no comprehensive plan of health instruction in 
the schools. This is unfortunate, because, when properly organized 
and operated, health instruction of school children is potentially the 
foundation of successful public health work. The knowledge of the 
principles of personal hygiene and public health does not come to 
one instinctively and is frequently the result of bitter experience. 
It is a difficult matter to change the habits of thought and action 
which have crystallized in the adult, and instruction to prevent 
faulty health habits and to produce an instinctive appreciation of the 
principles of health preservation is most effective when imparted in 
the proper manner at an early period in the child's life. 

The control of communicable diseases, the elimination of tuber- 
culosis, the eradication of social diseases, the prevention of hamper- 
ing physical defects, the lowering of the infant mortality rate, the 



SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 23 

lessening of the number of deaths from the so-called degenerative 
diseases and of the number of cases of insanity, can not be effected 
in fullest degree without active and intelligent cooperation of the 
individual and of the community. The basis of such cooperation is 
education. The cultivation of health habits and instruction in the 
elements of public health should properly begin in the home, but, 
unfortunately, this is not possible at present, and the school, there- 
fore, offers the most hopeful opportunity for such instruction. 

No form of health instruction in the schools will be as completely 
successful as possible unless the combined wisdom of the teaching 
staff and that of the school medical staff be utilized for this purpose. 

Health instruction should be conducted along the following lines: 

1 . Eeorganizing the teaching of hygiene in the regular courses and 
assigning it a place in the curriculum equal in importance to that of 
other major subjects. 

2. Organizing classes in physical training. 

3. Supplementing classroom instruction by individual and group 
instruction by — 

(a) Instructors in physical training; 

(6) School nurses in the school and at home; and 

(c) School physicians. 

4. Encouraging addresses by specialists from time to time. 

5. Utilizing domestic science classes for teaching food values and 
food preparation. 

6. Improving sanitary environment of school buildings and school 
grounds. 

7. Improving the medical inspection service. 

8. Employing only qualified school nurses. 

9. Providing hot school lunches. 

10. Organizing classes in first aid, nutrition classes, and open-air 
schools and using them for practical health instruction. 

11. Teaching accident prevention. 

12. Distributing health leaflets and inclosing leaflets dealing with 
particular diseases and defects with the notification to parents. 

13. Encouraging the preparation of exhibits, posters, and compo- 
sitions relating to health conservation. 

The advisability of sex instruction in schools is one of the most 
serious instruction problems confronting educators, and one which 
must be handled with the greatest circumspection if disastrous results 
are to be avoided. Not every teacher is qualified to give this in- 
struction, which must vary with and be adapted to the age and sex 
of the child. Sex instruction should not be undertaken by boards of 
education until funds become available for the preparation of specially 
qualified teachers. The work is yet in the experimental stage. 



24 SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 

Recommendations. 

The board of education has provided the nucleus of a very satis- 
factory system of school-health supervision. With but little addi- 
tional cost and some few readjustments, it can be made comparable 
with any in the country. The following recommendations are based 
largely on immediate needs and with a view to future improvement. 

I. COOPERATION WITH THE HEALTH AUTHORITIES. 

The designation of the commissioner of health as director of the 
department of hygiene of the "board of education is the first step 
toward combining the related functions of the educational and health 
authorities for the preservation of the health of the school children. 
This correlation of activities should be extended to include the 
nursing personnel of both organizations. The city should be redis- 
tricted and the nurses should be assigned in sufficient number to 
each district to furnish the combined school and public health nursing 
service. Under the present arrangement, homes are visited by school 
nurses, by the contagious-disease nurses of the division of public 
health, by the tuberculosis nurses, by the nutrition workers, by the 
nurses of the visiting nurses' association, and by representatives of a 
number of social agencies, greatly to the annoyance of those whom 
they wish to serve. Unification of the duties of the city-school and 
public-health nurses will permit of the assignment of qualified nurses 
in sufficient number to carry on these combined activities. Such an 
arrangement will be more economical and produce more satisfactory 
results than is possible under the present system. 

II. MEDICAL INSPECTION. 

Funds should eventually be made available for the employment of 
additional medical inspectors in the proportion of one physician to 
3,000 children. The number of school medical inspectors is entirely 
inadequate properly to perform the duties prescribed for them. In 
fact, as now performed, through no fault of the medical-inspection 
staff, the work of the school medical inspectors is hardly commen- 
surate with the cost. 

The work of the medical inspector should be under intensive 
supervision, medical inspection should be standardized, and the 
personal equation of individual examiners should be eliminated as 
far as is possible. 

With the employment of a sufficient number of school nurses, 
routine classroom inspection by the medical inspector should be 
permanently abandoned. However, inspectors should be required 
to visit the classrooms from time to time to observe sanitary condi- 
tions and advise with the teachers in respect to illumination, the 
seating of children, and the correction of postural defects. Further- 



SCHOOL HEALTH SUPERVISION IE" MINNEAPOLIS. 25 

more, the school medical inspector should lose no opportunity to 
advise with teachers and principals in respect to the physical and 
mental condition of individual children requiring special attention. 

With the present limited staff, physical examinations should be 
limited to the routine physical examination of children in the first 
and second grades, to special examinations of children about to leave 
school for employment, and children referred by teachers and nurses. 
As funds become available for the employment of additional in- 
spectors these examinations should be extended to include an 
annual examination also of children in the fourth and eighth grades. 

Medical inspectors should be required to exercise greater care in 
recording the results of physical examinations, and when parents are 
notified, notification should be accompanied by a specific statement 
of the child's physical and mental condition requiring attention. 

Every medical inspector should be required to visit each school 
in his district in daily rotation for the purpose of making routine 
physical examination of children and for the special examination of 
referred cases. By this arrangement, even with but slight increase in 
the present limited staff, each school would be visited at frequent 
intervals, .and the services of a school physician would be available 
for diagnostic purposes in referred cases. With a larger number of 
physicians, each school should be visited more frequently. 

Although, among the prescribed duties of the school physicians, 
but little attention is given to the sanitary condition of the school 
buildings and school grounds, owing to the fact that their limited 
time is fully occupied in making physical examinations, a general 
sanitary survey of all the schools should be made at the opening 
of each school year, which should be followed up by monthly inspec- 
tion of classrooms and sanitary conveniences. A detailed report of 
such surveys and inspections should be required of each school 
physician and made available for the information and guidance of 
the board of education and school principals. 

III. THE NURSING SERVICE. 

Ultimately the school nursing service and that of the division of 
public health should be combined; the school system should be 
redistricted, and the nurses assigned in the proportion of approxi- 
mately one nurse to every 1,000 children. The nurses should be 
required to devote the morning hours to work in the schools and the 
afternoons to follow-up and public-health work. 

The school nurse should be required, as now, to make classroom 
inspection at frequent intervals for the purpose of detecting con- 
tagious diseases. Classroom inspection made at infrequent intervals 
will do but little toward preventing the spread of the so-called com- 
municable diseases of childhood. Modern educational methods make 



26 SCHOOL HEALTH SUPERVISION" IN MINNEAPOLIS. 

such demands on the time and energy of the teacher that she should 
not be required, or expected, to be responsible for the detection of 
communicable diseases in their incipiency. This should be the 
responsibility of the nurse who is qualified by training and experience. 

The present practice of referring children with suspected defects 
to their parents on recommendation of the school nurse should be 
discontinued as promptly as possible. In each instance the notifi- 
cation should be accompanied by a specific statement of the defect 
or defects based on the physician's examination. 

The school nurse should be present at and assist in physical ex- 
aminations and act in other than mere clerical capacity. A clear 
understanding of the child's physical needs, gained through the 
sympathetic cooperation of the examining physician, will be of 
greatest benefit to her in follow-up work. 

The five nurses now engaged in assisting the school medical ex- 
aminers in physical examinations should be assigned to other duty. 

With the enlargement of the nursing staff and redistricting the 
schools, the supervising nurse should be allowed at least three as- 
sistants for the exercise of more intimate supervision of the school 
and public health nursing work. 

Conferences of the nurses should be held weekly, at which time 
they should receive special instruction in respect to the performance 
of their duties, and lectures on preventive medicine should be given 
by the members of the school medical staff and invited specialists, 
in order to prepare them for giving health instruction to individual 
children and to parents during home visits. 

Greater emphasis than is given to the work at present should be 
placed on home visits by the nurses. The work of the nurse in the 
home is probably one of the most important phases of school nurs- 
ing service, and it should be considered a necessary adjunct to 
special class work for securing the cooperation of the parent in 
order that the child may follow a prescribed regimen in the home. 
Furthermore, during these home visits the nurse can, with advan- 
tage, perform the prescribed duties of public health nurse from the 
standpoint of the control of communicable diseases, instruction in 
personal hygiene, and advice in respect to improvement in home 
sanitary conditions. 

IV. SPECIAL CLASSES AND SCHOOLS. 

The children enrolled in special classes should be under intensive 
medical supervision and included under the school medical inspec- 
tion service. The need is apparent for more intensive medical 
supervision and follow-up service for the children attending special 
classes. This is especially true of the open-air school and the school 
for crippled children, in order that cases of open tuberculosis may be 



SCHOOL, HEALTH SUPERVISION IN MINNEAPOLIS. 27 

discovered promptly and that contributing physical handicaps may 
be corrected in so far as may be possible. 

Attention has been directed in the body of this report to the 
importance of special examinations and of home visits to children 
attending sight saving, speech correcting, and nutrition classes, and 
classes for subnormal children. 

A careful physical and mental examination should be made of 
each child prior to admission to special classes, the results of which 
should be available for the information and guidance of the special 
teaching staff. In order that the maximum benefit may be derived 
from these examinations, it will be necessary in the near future to 
supplement the work of the present whole-time physician by addi- 
tional assistants. 

Additional facilities for health supervision and instruction in open- 
air classes is urgently needed. Classes should be organized in the 
larger schools as rapidly as funds become available to supplement 
the work of the open-air school, which is already taxed to capacity. 
The latter should be reserved for children in more urgent need of 
special attention. 

At the present time over 80 school children with active tuber- 
culosis have been reported to the director of hygiene. Obviously, 
these children should not be allowed to attend the general classes 
because of the danger of the spread of infection, and yet they should 
not be deprived of educational opportunity. However, their exclu- 
sion from school exercises a harmful mental effect by inferentially 
placing them in a class beyond the hope of salvage. It is recom- 
mended that prompt steps be taken for the establishment of classes 
for the instruction of ambulant cases of active tuberculosis under 
medical and nursing supervision. 

V. SCHOOL CLINICS. 

The board of education is scarcely justified at the time of this 
study in providing clinical facilities for the treatment of conditions 
other than disorders of vision, dental defects, and cardiac cases. 
These physical handicaps are so directly related to the child's progress 
in school and occur in such preponderating numbers as to make it 
extremely doubtful if they could be properly cared for by outside 
agencies and, therefore, warrant the provision of facilities for treat- 
ment by the board of education. 

It is recommended that all existing school clinical facilities be 
utilized to the fullest capacity and kept open the full school day 
instead of for one-half day as is now the practice. 

The five special nurses who now assist the medical inspectors in 
physical examinations should be assigned to these clinics for whole- 
time duty. 



28 SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 

Cardiac clinics. — The work in cardiac clinics is largely devoted to 
determining the exercise toleration, prescribing a regimen of daily 
living, and giving vocational training and guidance best adapted to 
individual cases. 

Approximately 2 per cent of the children in the Minneapolis 
schools will be found, on careful examination, to have a more or less 
damaged heart. Children attending school should be given a more 
careful examination than is now the practice for the detection of 
actual and potential cardiac cases. 

Special cardiac clinics should be organized under the supervision 
of the department of hygiene for instruction and advice and treat- 
ment appropriate to the degree of cardiac damage. 

Children suspected of having heart disease should receive a most 
careful physical examination, in order that contributing factors, such 
as nutritional disorders, bad teeth, diseased tonsils, adenoids, and 
rheumatic conditions, may be detected and corrected. A careful 
examination should be made of every child returning to school after 
an absence on account of an attack of tonsillitis, diphtheria, or scarlet 
fever, for evidences of cardiac damage. 

The work of the clinic should be supplemented by intensive follow- 
up in the homes and by vocational training adapted to the child's 
physical needs. Notification of parents should be required, and the 
cooperation of the parents' family physician should be secured, in 
order that the work of the clinic may be supplemented by intelligent 
supervision in the home. 

The advisability of opening special cardiac classes in the schools 
depends very largely on local conditions. In general, the instruction 
issued by the board of education of New York City to the teachers, 
if followed, will answer ordinary needs. These instructions are in 
part as follows: 

(1) To issue special passes to permit pupils with heart disease to 
use special entrances and exits. 

(2) To permit these children to enter or leave school directly before 
or after the regular time schedule for normal children. 

(3) To excuse cardiacs from physical training, fire drills, etc. 

(4) To lengthen the lunch hour in order to avoid hurry and haste 
in eating. 

It should be the duty of the school physician, on the advice of the 
director of cardiac clinics and the family physician, to advise with 
principals in respect to the proper regimen to be followed by in- 
dividual children. 

Denial clinics. — The number of dentists employed is entirely 
inadequate properly to attend to the dental needs of the Minneapolis 
school children. 

Preventive dental service should be furnished to all children under 
12 years of age, irrespective of their social and economic status, thus 



SCHOOL HEALTH SUPERVISION IF MINNEAPOLIS. 29 

eliminating the charitable aspect of such work when restricted to 
necessitous children. However, until additional dental facilities are 
provided, preferential service should be given to the children in the 
primary grades and to neglected children in the other grades who are 
in urgent need of attention. 

When funds become available, mouth hygienists should be em- 
ployed in the proportion of one hygienist to each school district. 
This number may be increased to meet the growing demand for such 
services as rapidly as funds become available. 

The dental clinics should be in charge of whole-time dentists and 
should be kept open during school hours and on Saturdays. 

The work of the dentists should be standardized, with the view of 
eliminating the personal equation of individual dentists and in the 
interest of economy. 

As much work as possible should be done at each sitting as is 
compatible with the comfort and endurance of individual children, 
in order to economize in the time of the dentist, the child, and the 
nurse. 

A complete dental record should be kept of each child. This 
should follow him from class to class. The accompanying form is 
recommended as well adapted for this purpose. 



30 



SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 




SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 



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32 SCHOOL. HEALTH SUPERVISION IN MINNEAPOLIS. 

Eye clinics. — Additional facilities for special eye work should be 
provided in the near future, and this service should be made a part 
of the school health supervision system. The physicians in direct 
charge should be under the supervision of the director of hygiene 
and paid by the board of education. 

VI. NUTRITION WORK. 

Children enrolled in nutrition classes should first receive a careful 
physical examination, the results of which should be a part of the 
child's class record. The special instruction given to the children 
enrolled in these classes should be under the direct supervision of 
the director of hygiene and be considered a part of the medical school 
inspection service. 

In addition to special advice and instruction given to individual 
children, mothers should be encouraged to attend these classes for 
instruction, individually and in groups, in order that the fullest 
cooperation may be obtained in the homes. Intensive follow-up 
work by the school nurse is essential to the success of nutrition 
classes. 

Steps should be taken to secure accurate height and weight measure- 
ments, periodically, of all the children in the first to eighth grades, 
inclusive, in order that a local standard of physical development 
applicable to sex and age periods may be calculated. Such a stand- 
ard is of highest importance in the selection of candidates for the 
nutrition classes, and as one of the means of checking the value of 
the work from the standpoint of individual children. 

VH. PHYSICAL TRAINING. 

Owing to the intimate relationship of physical training to pre- 
ventive medicine, it is recommended that the board of education 
reverse its action and make physical training a subdivision, and 
make the director of physical training an assistant director of the de- 
partment of hygiene. The physical training work should be corre- 
lated with the school medical inspection service. 

VIII. HEALTH EDUCATION. 

Greater prominence should be given to health education work in 
the schools. This should include the preparation of instruction 
matter adapted to the age of the child, correlation of the work of 
the teaching staff with that of the school medical, physical training, 
and nursing personnel, and the organization of the children in practi- 
cal health work in the schools and in their homes. 

Practical health education should be emphasized in the special 
classes, and the children in all the classes should be encouraged in the 



SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 33 

preparation of compositions, posters, and exhibit material relating 
to health subjects. 

The director of hygiene, the school medical inspectors, and the 
school nurses should stand in closer cooperative relation with teachers 
and principals, and the subject of health education and health 
supervision should be discussed in conferences requiring compulsory 
attendance. 

The teaching of health in the schools should be given a place in the 
curriculum equal in importance to that of major subjects. 

IX. SCHOOL RECORDS. 

No hard and fast recommendations can be made regarding school 
medical record forms. In general, the forms should be so devised as 
to make available at all times accurate information regarding the 
child's physical and mental condition, the relation of the physical 
and mental handicaps to school progress, the extent to which these 
handicaps have been removed, the effect of remedial measures on 
the child's health and school progress, and the efficiency of follow- 
up work in bringing about the relief of harmful conditions. The 
record should accompany the child's scholastic record throughout his 
school career. 

Greater care than seems to be the present practice should be 
exercised in recording the results of physical examinations in specific 
terms. 

At present no attempt is made to make use of the material collected 
in the course of physical examinations. All statistical material 
should be compiled and submitted to the board of education in an 
annual report showing the prevalence of physical and mental handi- 
caps, the corrections made, and the improvement, if any, in the 
physical and mental efficiency of the children from year to year. 
In other words, the public can not be expected to support in a whole- 
hearted manner this very important work unless its value can be 
clearly demonstrated. 

The accompanying form adopted by the Public Health Service may 
serve a useful purpose in the preparation of a schedule for recording 
the results of medical inspections in accordance with the suggestions 
made in the body of this report. 



34 



SCHOOL HEALTH SUPERVISION" IN MINNEAPOLIS. 



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36 SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 



X. COOPERATION OP VOLUNTEER AGENCIES. 



Keference is made in the body of this report to the work of a 
number of private agencies in the schools. It is beyond question 
that such cooperation is and has been of value in paving the way and 
demonstrating the need of certain forms of health supervision. How- 
ever, there is a limit to the extent and the length of time these agencies 
should assume the responsibility of the constituted authority. The 
health work in the special classes and special schools, including 
nutrition work, should be administered by the board of education 
under the supervision of the director of hygiene, and made an integral 
part of the health supervision system. It is only by such centralized 
administration and supervision that school health supervision can 
reach its highest degree of completeness and effectiveness, and that 
the interruption of class work will be reduced to a desirable minimum. 



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